I came across this question whilst researching CBT for a course I am studying.
The short answer
As I will cover in the long answer, there has been a lot of articles stating that CBT is very effective, and there are articles which have stated that it is not as effective as has been claimed.
CBT is not a single model of therapy, applicable to all clients in all situations. This has been one of the criticisms levelled at CBT, that its 'one size fits all' approach to the complex nature of human problems will, inevitably, fail to meet the needs of many, or (at best), simply focus on symptom reduction. (Reeves, 2013)
There are a fair few factors which can prevent CBT from becoming effective, and a trained and certified CBT practitioner will be able to assess the suitability of CBT. If they operate ethically, they will not go ahead with providing CBT to someone who it would not benefit.
One of the biggest factors which doesn't allow CBT to work is that if the client is not willing or able to challenge their thoughts and behaviours, then CBT will not be effective.
For the long answer, which will help to explain some of the reasons why CBT may not work with some people, I will be using a lot of the work I put into an essay I had to write for my psychotherapy course which covered Cognitive Behavioural Therapy (CBT) and integrative approaches to therapy.
CBT is an integrative model of approach and we had to look at how an integrative approach may be used to support the client within a case study provided.
Case study provided
Hassan has been referred to you for work-related stress and anxiety. He has a management position and is finding it difficult to cope. At present the information you have is that he is a 42 years old Muslim man, married with 2 children. He has lived in the UK since the age of 5 when his parents travelled here. His father died two years later and Hassan, as the eldest son, has felt responsible for the wellbeing of his mother and sisters as well as his own family.
Your referral is through an employee assistance scheme. Hassan’s assessment shows high level of anxiety without depression. He is otherwise fit and healthy. You may offer him six sessions with a further six sessions if appropriate.
An article (Dhami & Sheikh, 2000) adapted from a chapter in Caring for Muslim Patients, published by Radcliffe Medical Press, Oxford, England; provides key insights needed to allow Muslim clients' concerns to be adequately heard. The vignettes section of the article gives a few sayings of Muhammad regarding relationships with parents and one of them points out that you should “strive to serve them”.
If the client has had the opportunity to fully integrate with the western culture they are living in, they may be more open to challenging their thoughts and beliefs, however we need to be mindful that as therapists, just like we are not here to judge, for an example, on sexuality (Pink Therapy, 2016) (UKCP, 2015), we are not in a position to judge whether a cultural or religious belief is right or wrong, especially when we are not priests, vicars, rabbis, imams or the like. Not only that, if the client is devout in their religious beliefs, then we are not going to change those beliefs very easily, if at all. (Babilonia, 2015)
The only time when we can intervene in any religious or cultural beliefs is when it is believed that laws may be broken such as the FGM Act (Home Office, 2016) (Crown Prosecution Service, n.d.), in which case, we would refer the legal case to the necessary authorities and it would be down to the legal profession and not the therapist.
Strengths and Limitations of integrative approaches to counselling
Integrative counselling and psychotherapy can be seen as one of the most effective approaches within counselling. (The Counselling Directory, 2013) The idea behind the integrative approach is that no single approach suits every client and therefore you use different approaches and models of therapy to suit the situation and client. The article within The Counselling Directory cited also states that integrative therapy has four different categories:
- common factors
Looking at the common tools available in each approach that can be useful in the therapy. Therapist/Client rapport, therapist qualities – positive regard, and congruence etc. – emotional release, and clarification etc.
- technical eclecticism
The therapist looks at and selects the best interventions by relying on experience and knowledge of what has worked in the past for others, through theories and research literature.
- theoretical integration
The combination of two approaches with a common philosophy. The combined ideas are theoretically the same as each other. For example, cognitive behavioural therapy (CBT) is part of the theoretical integration category, as it is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013), plus, cognitive analytical therapy is also a theoretical integration of psychodynamic therapy and cognitive therapy.
- assimilative integration
The therapist primarily sticks to one therapeutic approach, for example Humanistic or psychodynamic, but the therapist will use strategies and models from other therapeutic approaches as well. The combination of ideas will assimilate the pure form of the primary therapeutic approach.
The limitations of any integrative therapy depend on the category of integration.
One problem identified in theoretical integration is that it is difficult to integrate some theories; for example, it is difficult to integrate psychodynamic theory and behavioural theory. The psychodynamic approach suggests that our early experiences from birth onwards and their impacts lead to our psychological problems, where behaviour theory sees problems as much more agreeable to change (Reeves, 2013). These differences result in incompatibilities between these theories.
With this kind of integration, there is no balance compared to the other forms of integration. Where the therapist is primarily psychodynamic or humanistic, for example, they will pick and choose ideas from other approaches which may not be put forward by their primary approach, but can work very effectively and contribute to the treatment or treatment plan.
This shares similarities and differences with assimilative integration, but it has no theoretical underpinning to the approach. (The Counselling Directory, 2013)
As CBT is a theoretical integrative model, and it is difficult to integrate some theories, CBT cannot and does not incorporate any psychodynamic theories. However, if you are going to work in a fully integrative manner, you need to bear in mind the theories within the psychodynamic approach too. If therapy seems to need some psychodynamic interventions, then you may need to drop CBT sessions sometimes and concentrate on the psychodynamic interventions, maybe through Cognitive Analytical Therapy instead, before continuing with CBT.
The basic concept of CBT
Cognitive Behavioural Therapy (CBT) was developed by [Aaron Temkin Beck], and as mentioned before, CBT is a combination of behaviourism and behaviour therapy, and cognitive theories and their application in therapeutic settings (Reeves, 2013). CBT helps to change how you think, hence the word *Cognitive*, and what you do, hence the word *Behaviour*.
A difficult life situation, relationship or practical problem can lead to:
- Altered thinking
- Altered emotions and feelings
- Altered behaviour
- Altered physical feelings or symptoms
Things can happen the other way too. Any of the above alterations can lead to a difficult life situation, relationship or practical problem (Royal College of Psychiatrists, n.d.).
CBT works by trying to get the client to think about a situation in a more helpful way in order to move forward using more helpful behaviours.
The basic concept of REBT
Rational Emotive Behaviour Therapy (REBT) has generally been put under the same umbrella as CBT, however although it has similarities, REBT is different. Where CBT was developed by [Aaron Beck], REBT was developed by [Albert Ellis] when he started to lose faith in the type of psychoanalysis he was using.
REBT is a practical and action-led model of therapy and personal growth. It doesn’t just focus on the client’s behaviours, but also allows the client to understand the behaviours of others and provide techniques that will help to solve future problems.
Although REBT looks primarily at our current beliefs and behaviours, it also looks at the cause and effect of past experiences and beliefs which create our present beliefs and behaviours. It does this whilst aiming to change irrational beliefs into rational ones quickly rather than slowly, however, one key point to note is that the therapist does not impose rational beliefs on the client, but accepts there are non-rational beliefs that may help people achieve happiness. That way, the therapist is accepting the client’s value system.
REBT, uses an A-B-C-D-E formula.
- Activating Experience
Also referred to by some as the Initial Sensitising Event (ISE), this is the root cause of our unhappiness
Irrational self-defeating beliefs that are the source of our unhappiness, or come about as a result of the ISE
The neurotic symptoms and negative feelings and emotions that result from the ISE and/or Beliefs
We must dispute and challenge these irrational beliefs in order for the client to enjoy a balanced outlook in life
The client must learn to enjoy the effects of the new rational beliefs and get used to the changes, letting them become the new norm.
The shortfalls of CBT
As mentioned before, One of the ideas put forward about CBT is that it is a suitable form of therapy for all human problems. This idea can be damaging in some respects, as CBT is not suitable for all psychological conditions.
Interestingly, whilst researching the overall efficacy of CBT, I came across a few items of note.
- Carl Rogers emphasised the quality of the therapeutic relationship as a necessary and sufficient condition for successful therapy (Rogers, 1957) whereas CBT therapists tend to see the alliance as more instrumental in ensuring the patient’s adherence to the treatment protocol (e.g. Dunn, et al., 2006) (Goldsmith, et al., 2015)
- The Countess of Mar in the House of Lords suggested the results of a trial into the effectiveness of CBT and GET (graded exercise therapy) had been artificially inflated (BACP, 2013)
The fact is that, as opposed to the spin that accompanied the publication of selective results, only 15% of patients improved with CBT and GET, leaving 85% with no benefit from those interventions. Furthermore, of the combined CBT/GET groups of 321 people, 91% experienced adverse events
[The UK Medical Research Council] PACE trial PIs [Principal Investigators] changed the primary outcome measures with the intention of artificially inflating the success of CBT and GET—treatments they promoted for more than 20 years—and that, consequently, they are guilty of scientific misconduct. (UK Parliament, 2013)
…CBT is ‘probably effective’ with major depression, general anxiety disorder, panic disorder and social anxiety disorder, but not as effective as has been claimed, due to publication bias, poor quality of studies, and the use of waiting list control groups as a comparator. (BACP, 2016)
- CBT is as much based on the development of a therapeutic alliance as it is in a psychodynamic and humanistic approach. The success of therapy will be, at least partly, informed by the nature of the therapeutic process, and not simply the application of particular theoretical ideas, as some suggest (Reeves, 2013)
- Recent literature provides fairly strong evidence that CBT in addition to antipsychotic medication is effective in the management of acute as well as chronic schizophrenia (Rathod & Turkington, 2005). However, I would stress that CBT was not used alone in any of these studies from what I have seen. It was used carefully in conjunction with psychiatric help and antipsychotic medication.
An alternative to CBT called Metacognitive Therapy (MCT) has been touted to be better than CBT. But it was developed by Manchester University (Addelman, 2020) and studied by Manchester University (Wells, 2019) so more independent studies are needed.
Either way, if the client is not able or willing to challenge their thoughts and behaviours, then CBT will not be effective.
Addelman, M. (2020). *New therapy more effective than cognitive behavioral therapy for depression.*
Retrieved from: https://medicalxpress.com/news/2020-05-therapy-effective-cognitive-behavioral-depression.html
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Dhami, S. & Sheikh, A. (2000). The Muslim family: predciament and promise. The Western Journal of Medicine, 173(5), pp. 352-356. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071164
Dunn, H., Morrison, A. P. & Bentall, R. P. (2006). The relationship between patient suitability, therapeutic alliance, homework compliance and outcome in cognitive therapy for psychosis. Clinical Psychology & Psychotherapy, 13(3), pp. 145-152. https://doi.org/10.1002/cpp.481
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Home Office. (2016). Mandatory reporting of female genital mutilation: procedural information.
Retrieved from: https://www.gov.uk/government/publications/mandatory-reporting-of-female-genital-mutilation-procedural-information
Pink Therapy. (2016). Why I am resigning from the British Association for Counselling and Psychotherapy. Retrieved from: https://pinktherapyblog.com/2016/02/17/why-i-am-resigning-from-the-british-association-for-counselling-and-psychotherapy/
Rathod, S. & Turkington, D. (2005). Cognitive behaviour therapy for schizophrenia: a review. Current Opinion in Psychiatry, 18(2), pp. 159-163. https://doi.org/10.1097/00001504-200503000-00009
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Rogers, C. (1957). The Necessary and Sufficient Conditions of Therapeutic Personality Change.
Retrieved from: http://www.shoreline.edu/dchris/psych236/Documents/Rogers.pdf
Royal College of Psychiatrists. (n.d.) 5 Areas Assessment.
Retrieved from: https://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/cbt/5areas.aspx
The Counselling Directory. (2013). Integrative Psychotherapy as an Effective Form of Counselling.
Retrieved from: http://www.counselling-directory.org.uk/counsellor-articles/integrative-psychotherapy-is-the-best-approach
UKCP. (2015). Memorandum of Understanding (MoU) on Conversion Therapy in the UK.
Available at: https://www.psychotherapy.org.uk/wp-content/uploads/2016/09/Memorandum-of-understanding-on-conversion-therapy.pdf
UK Parliament (2013). PACE Trial: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis - House of Lords Grand Committee
Available at: https://hansard.parliament.uk/lords/2013-02-06/debates/130206114000195/PACETrialChronicFatigueSyndromeMyalgicEncephalomyelitis
Wells A (2019) Breaking the Cybernetic Code: Understanding and Treating the Human Metacognitive Control System to Enhance Mental Health. Frontiers in Psychology, 10(2621). https://doi.org/10.3389/fpsyg.2019.02621